Complex periprosthetic wound coverage in patients undergoing revision total knee arthroplasty: a single plastic surgeon study.

INTRODUCTION: Options for soft tissue coverage in revision total knee arthroplasty (rTKA) range from primary wound closure to complex muscle flap reconstructions. The purpose of this study was to investigate the institutional experience of wound coverage options for complex soft tissue defects in rTKA. MATERIALS AND METHODS: 77 patients undergoing rTKA with complex wound closure by a single plastic surgeon were retrospectively reviewed. The average follow-up was 30.1 months. In 18 (23.4%) patients, an intraoperative decision for primary closure was made. Fifty-nine patients (76.6%) received either a local fasciocutaneous (N = 18), a medial gastrocnemius (N = 37), a free latissimus dorsi (N = 3) or a lateral gastrocnemius flap (N = 1). Revision-free survival and complication rates were assessed and risk factors were analyzed with Cox-regression analysis. RESULTS: Medial gastrocnemius flaps had significant lower cumulative revision-free survival rates than local fasciocutaneous flaps (P = 0.021) and primary closures (P < 0.001) (42.5% vs. 71.5% vs. 100%,respectively). Comparing the most common complex closure procedures medial gastrocnemius flaps had the highest rate of prolonged wound healing (29.7%) and infection/reinfection (40.5%). Infection-associated flap procedures had significant lower cumulative revision-free survival rates (30.5%) than non-infection associated flap procedures (62.8%,P = 0.047). A history of more than two prior surgeries (HR = 6.11,P < 0.001) and an age ≥ 65 years (HR = 0.30,P = 0.018) significantly increased the risk of revision. CONCLUSIONS: The results of this study indicate that primary closure -if possible- should be preferred to early proactive muscle flap coverage. Even in the hands of an experienced plastic surgeon muscle flaps have high revision and complication rates. The study highlights the need to clarify flap indications and to investigate alternative approaches.

Supraclavicular Artery Island Flap for Treatment of Cervical Wound Defects and Persistent Cerebrospinal Fluid Leaks: A Technical Note and Systematic Review of the Literature.

BACKGROUND: Soft tissue defects and persistent cerebrospinal fluid (CSF) leaks can create complications after cervical spinal surgery. The supraclavicular artery island (SAI) flap is useful in closing tissue defects, particularly in these complex surgeries and multiple reinterventions. However, technical reports in this context are scarce. We describe application of the SAI flap technique to control persistent CSF leak in the first documented instance (to our knowledge) of a low-grade fibromyxoid sarcoma (LGFMS) in the cervical epidural space. Additionally, we conducted a comprehensive review of PubMed, Embase, and Google Scholar from their earliest records through December 17, 2023 using combined terms, "supraclavicular artery island flap AND spine" and "supraclavicular AND flap AND spine". TECHNICAL NOTE: A 56-year-old woman with arm pain and weakness presented with a cervical epidural mass extending from C4-C6 and associated spinal cord compression. She underwent a 3-level corpectomy and tumor resection. Primary dural closure was impossible due to the dural invasion, and reintervention with an SAI flap and definitive lumboperitoneal shunting were required to control and seal the CSF leak. SYSTEMATIC LITERATURE REVIEW: Seven case reports describing SAI flap for spinal surgery complications were identified. The indications in those cases were correcting esophageal and hypopharyngeal perforations after cervical fusion and discectomy and persistent soft tissue coverage after cervical instrumentation. CONCLUSIONS: The SAI flap technique provided wound defect coverage in this case and is suitable for addressing issues such as persistent CSF leaks or soft tissue coverage after cervical spine surgery.

Reconstruction of lower limb defect with a variant sural neuro-fasciocutaneous flap: A case report.

INTRODUCTION: The sural neuro-fasciocutaneous flap is widely used for reconstructing skin defects in the lower calf. Variations of the sural nerve in the calf are infrequent, which may require a variation in the traditional surgical procedure. CASE PRESENTATION: A 76-year-old male patient had soft tissue defect of the right lateral ankle and lower leg caused by an accident 18 years ago. He had exposed bones and had osteomyelitis. He underwent two primary operations, and finally, we used a sural neuro-fasciocutaneous flap to effectively cover the defect. We observed that the course of the sural nerve was atypical during the surgery, and we adjusted the flap axis laterally to bring the lateral sural cutaneous nerve inside the flap to improve the success rate of the surgery. The flap entirely survived, and there was no sensory impairment in the calf. The patient was discharged from the hospital after 10 days. CLINICAL DISCUSSION: Some type of variant of the sural nerve makes the flap harvest without the neurovascular component of the sural nerve and the cutaneous chain, which might decrease flap survival. Moving the flap axis laterally and bringing in the lateral sural nerve or peroneal communicating nerve offers an adequate blood supply to the vascular territory and the flap region. CONCLUSION: In patients with sural nerve variants, the procedure does not have to follow the traditional theory of the sural neuro-fasciocutaneous flap. Preoperative and intraoperative protection of the sural nerve variant should also be considered.

Standardized Pre-clinical Surgical Animal Model Protocol to Investigate the Cellular and Molecular Mechanisms of Ischemic Flap Healing.

BACKGROUND: Some of the most complex surgical interventions to treat trauma and cancer include the use of locoregional pedicled and free autologous tissue transfer flaps. While the techniques used for these reconstructive surgery procedures have improved over time, flap complications and even failure remain a significant clinical challenge. Animal models are useful in studying the pathophysiology of ischemic flaps, but when repeatability is a primary focus of a study, conventional in-vivo designs, where one randomized subset of animals serves as a treatment group while a second subset serves as a control, are at a disadvantage instigated by greater subject-to-subject variability. Our goal was to provide a step-by-step methodological protocol for creating an alternative standardized, more economical, and transferable pre-clinical animal research model of excisional full-thickness wound healing following a simulated autologous tissue transfer which includes the primary ischemia, reperfusion, and secondary ischemia events with the latter mimicking flap salvage procedure. RESULTS: Unlike in the most frequently used classical unilateral McFarlane's caudally based dorsal random pattern skin flap model, in the herein described bilateral epigastric fasciocutaneous advancement flap (BEFAF) model, one flap heals under normal and a contralateral flap-under perturbed conditions or both flaps heal under conditions that vary by one within-subjects factor. We discuss the advantages and limitations of the proposed experimental approach and, as a part of model validation, provide the examples of its use in laboratory rat (Rattus norvegicus) axial pattern flap healing studies. CONCLUSIONS: This technically challenging but feasible reconstructive surgery model eliminates inter-subject variability, while concomitantly minimizing the number of animals needed to achieve adequate statistical power. BEFAFs may be used to investigate the spatiotemporal cellular and molecular responses to complex tissue injury, interventions simulating clinically relevant flap complications (e.g., vascular thrombosis) as well as prophylactic, therapeutic or surgical treatment (e.g., flap delay) strategies in the presence or absence of confounding risk factors (e.g., substance abuse, irradiation, diabetes) or favorable wound-healing promoting activities (e.g., exercise). Detailed visual instructions in BEFAF protocol may serve as an aid for teaching medical or academic researchers basic vascular microsurgery techniques that focus on precision, tremor management and magnification.

Key aspects of soft tissue management in fracture-related infection: recommendations from an international expert group.

A judicious, well-planned bone and soft tissue debridement remains one of the cornerstones of state-of-the-art treatment of fracture-related infection (FRI). Meticulous surgical excision of all non-viable tissue can, however, lead to the creation of large soft tissue defects. The management of these defects is complex and numerous factors need to be considered when selecting the most appropriate approach. This narrative review summarizes the current evidence with respect to soft tissue management in patients diagnosed with FRI. Specifically we discuss the optimal timing for tissue closure following debridement in cases of FRI, the need for negative microbiological culture results from the surgical site as a prerequisite for definitive wound closure, the optimal type of flap in case of large soft tissue defects caused by FRI and the role of negative pressure wound therapy (NPWT) in FRI. Finally, recommendations are made with regard to soft tissue management in FRI that should be useful for clinicians in daily clinical practice.Level of evidence Level V.

Is a pedicular flap coupled to the double turnover flaps urethroplasty suitable for urethral-perineal reconstruction? Considerations about a relapsing urethral-cutaneous fistula condition.

Background: This study highlights the effectiveness, in one surgical stage, of two combined local techniques for perineal fistula repair in a patient with spinal cord injury: the " Turn over flaps urethroplasty" and the "Pedicular fasciocutaneous flap" from the inferior gluteal fold. Unlike the traditional Perforator flap, we harvested a Pedicular flap; by definition, this is a flap with a narrow diffuse microvascular supply aimed in our case at shielding the neourethra and substituting the remaining scarred perineum. Method: The urethroplasty technique adopted, the 'Double turn over flaps urethroplasty', has been based on sculpting two opposing local cutaneous flaps circumscribing the fistulous cutaneous openings. Eventually, the neourethra continuity has been re-established by turning over both flaps and making them meet medially. The dimension and thickness of the "Pedicular fasciocutaneous flap", have been considered to prevent any damage to the urethroplasty and at the same time to replace all the debrided scarred perineal tissue. Results: The follow-up confirmed a well-consolidated supple perineal area and a competent neourethra. Conclusions: The "Pedicular flap" is by definition a random vascular flap nourished through a narrow pedicle, not based on a single perforator but only on a diffuse, spread micro-perforators. When associated with the double "Turn over flaps urethroplasty", it represents a possible alternative to achieve satisfactory results for those physical and psychological challenges encountered in the treatment of recurrent urethral fistula of the perineum in a patient with spinal cord injury.

The distal fibular perforating axial flap for lateral malleolus coverage: an anatomical description and surgical technique.

PURPOSE: Skin closure disorders in ankle surgery are a recurrent problem not only in traumatology but also in elective surgery. The aim of the study was to describe the anatomical basis of the fasciocutaneous vascularization of the lateral malleolus region to develop a posterior cover flap for the region. METHODS: We dissected ten fresh frozen specimens after arterial injection of an Indian ink preparation and individualized the perforating arteries. Their positions and diameters were collated. Then, the surgical technique was clinically applied for two different cases by transferring the fasciocutaneous flap posterior to the lateral malleolus to cover a loss of skin substance. RESULTS: There were in average 5 fibular perforators over the last 100 mm of the fibula. The average diameter of the first two perforating arteries was 0.6 ± 0.12 mm and 0.9 ± 0.25 mm, respectively, and the consistency of the latter makes it possible to produce a skin flap with anterior translation. This is an axial flap. Two patients were operated on using this technique. There was no necrosis of the posterior fibular flap and healing was achieved by the third post-operative week. CONCLUSION: This study showed the presence of fibular perforating arteries with a high reproducibility of their dissection. This anatomical description served as the basis for the description of a new distal fibular perforating flap.

Long-term patient-reported donor-site morbidity after free peroneal fasciocutaneous flap in head and neck reconstruction.

OBJECTIVE: Fasciocutaneous free flap based on the peroneal artery (boneless version) is an option in our practice for head and neck reconstruction. However, the associated donor-site morbidity has rarely been discussed. Thus, this study investigated the long-term patient-reported donor-site morbidity associated with peroneal flaps. METHODS: In this single-center, retrospective, observational study, 39 patients who underwent a free peroneal flap were enrolled. We evaluated donor-site morbidity with a modified questionnaire from Enneking et al. and Bodde et al. RESULTS: Patient-reported daily life limitation was relatively low (5/39; 12.9%). Donor-site morbidities, namely pain (4/39; 10.3%), sensory disturbance (9/39; 23.1%), and walking limitation (9/39; 23.1%) were reported; most were rated minimal in severity. Among patients with walking limitation, muscle weakness (3/39; 7.7%), ankle instability (6/39; 15.4%), and gait alternation (6/39; 15.4%) were reported. Six patients developed claw toe. CONCLUSION: Balancing successful reconstruction and donor-site morbidity is challenging. This long-term patient-reported survey revealed that harvesting peroneal flaps resulted in minimal or minor donor-site morbidity with no obvious impacts on the patients' daily quality of life. Although free radial forearm flaps and anterolateral thigh flaps are standard, free peroneal flaps have been proven reliable, with acceptable donor-site morbidity.

Comparison of inferior gluteal artery perforator flaps versus vertical rectus abdominis musculocutaneous flaps in the reconstruction of perineal wounds.

BACKGROUND: Achieving a healed perineal wound following chemoradiotherapy and abdominoperineal resection (APR) is challenging for surgeons and patients. Prior studies have shown trunk-based flaps, including vertical rectus abdominis myocutaneous (VRAM) flaps, are superior to both primary closure and thigh-based flaps; however, there has been no direct comparison with gluteal fasciocutaneous flaps. This study evaluates postoperative complications after various methods of perineal flap closure of APR and pelvic exenteration defects. METHODS: Retrospective review of patients who underwent APR or pelvic exenteration from April 2008 through September 2020 was analyzed for postoperative complications. Flap closure techniques, including VRAM, unilateral (IGAP), and bilateral (BIGAP) inferior gluteal artery perforator fasciocutaneous flaps, were compared. RESULTS: Of 116 patients included, the majority underwent fasciocutaneous (BIGAP/IGAP) flap reconstruction (n = 69, 59.6%), followed by VRAM (n = 47, 40.5%). There were no significant differences between group patient demographics, comorbidities, body mass index, or cancer stage. There were no significant differences between BIGAP/IGAP and VRAM groups in minor complications (57% versus 49%, p = 0.426) or major complications (45% versus 36%, p = 0.351), including major/minor perineal wounds. CONCLUSIONS: Prior studies have shown flap closure is preferable to primary closure after APR and neoadjuvant radiation but lack consensus on which flap offers superior postoperative morbidity. This study comparing outcomes of perineal flap closure showed no significant difference in postoperative complications. Fasciocutaneous flaps are a viable choice for the reconstruction of these challenging defects.

Empirical Evidence on the Reliability of Lateral Supramalleolar Flap over Reverse Sural Flap for Local Soft Tissue Coverage of Dorsum of the Foot and Ankle Defects.

Background Soft tissue coverage of the distal foot and ankle region has been an area of debate due to the paucity of local flap options. To provide empirical evidence on the reliability of an underreported local alternative for foot and ankle defects, we aim to compare the lateral supramalleolar flap (LSMF) to the reverse sural flap (RSF). Methods During 2016-2019, 48 patients were divided randomly into two equal groups, LSMF and RSF groups respectively. The patients' demographic, surgical, and clinical outcome details were recorded and analyzed. Results Flap necrosis was found in five patients in the group treated with RSF and none in the LSMF group. The mean total number of stages in RSF group was significantly higher than in LSMF group ( p < 0.05). The mean operative time for patients in LSMF group was 85.8 ± 18.5 and 54.2 ± 11.2 in RSF group ( p < 0.05). Five patients in the RSF group needed additional procedures following flap complications. Nine patients in the LSMF group reported satisfaction outcomes to be "excellent," five patients reported "good" whereas, in the RSF group, 14 patients reported "excellent," 5 reported "good," 3 reported "fair," and 2 reported "poor" outcomes. Compared to the RSF (46.4 ± 4.3) group, the LSMF group had significantly better foot function indices (34.03 ± 3.9). Conclusion The lateral supramalleolar flap for foot and ankle defects offers better results, reduced complications as well a lesser number of stages and secondary procedures over the traditionally used reverse sural flap.

Cutaneous squamous cell carcinoma with secondary parotid metastasis: a case report.

Background: Majority of cutaneous squamous cell carcinoma (cSCC) originate in the head and neck region, with 1-3% have been found to have parotid or periparotid lymph nodes metastases. The significance of secondary parotid metastases from cSCC lies in its propensity of cervical lymph node spread and distant metastases leading to a dismal prognosis, and therefore the importance of early diagnosis and prompt treatment. Case Description: An 85-year-old gentleman with prior history of right temporal squamous cell carcinoma (SCC) presented with a new onset left cheek cSCC. He underwent complete excision with clear margin. Four months following initial surgery, he developed ulcerative mass at left angle of mandible. CT scan revealed an underlying left parotid gland tumor, which was confirmed to be SCC by fine needle aspiration cytology (FNAC). He was then surgically treated with nerve-sparing total parotidectomy, modified radical neck dissection, soft tissue reconstruction using free anterolateral thigh fasciocutaneous flap and adjuvant radiotherapy with satisfactory outcomes. Conclusions: Although rare, metastatic cutaneous SCC to parotid gland represents a unique group of locally advanced cutaneous SCC. Multimodal treatment approach consisting of total parotidectomy, ipsilateral neck dissection and adjuvant radiotherapy has been shown to improve the locoregional control of the disease and limit the propensity to distant metastasis.

Preference for Fasciocutaneous Flap Over Musculocutaneous Flap as a First-Line Option for Ischial Pressure Wound Reconstruction: A Review of 64 Cases.

The ischial pressure wound usually comprises a large, extensive defect and involves the repair of more than a small opening. Most surgeons have used a musculocutaneous flap to fill the large dead space of an ischial pressure wound. However, sacrificing muscle tissue has a potential risk of postoperative bleeding. The transferred muscle ultimately loses function as a cushion to absorb pressure. Conservation of muscle structures may be beneficial for use in future recurrence, which is common with ischial pressure wound. We compared the difference in outcome between musculocutaneous and fasciocutaneous flaps and analyzed factors affecting complications with the flaps in ischial pressure wound reconstruction. This study reviewed the results of 64 flaps in 44 patients with ischial wounds. The wounds were reconstructed with 34 musculocutaneous flaps (53%) and 30 fasciocutaneous flaps (47%). Twenty-three cases (36%) had complete healing, and 41 (64%) had complications. There was no significant difference in outcomes between fasciocutaneous and musculocutaneous flap groups. Crude logistic regression analysis showed no significant risk factors for occurrence of major complications. When fasciocutaneous flaps were used, the neighboring perforators and muscle tissues could be conserved. With a perforator-based fasciocutaneous flap, a de-epithelized distal portion of the flap could be used to fill the dead space. Therefore, the fasciocutaneous flap may have priority over the musculocutaneous flap as a first-line option for ischial pressure wound reconstruction.

10-Year Experience with the Modified Pectoralis Major Flap: The Use of the Deltopectoral Flap to Reduce Skin Tension.

Purpose: Pectoralis major myocutaneous flap has been the work horse flap for head and neck reconstruction. However, due to the bulky nature of the pedicle it is not uncommon to struggle to achieve tension free closure of the neck skin incision. This case series presents a modified pectoralis major flap technique to overcome the difficulty of tight closure or the need to graft the residual cutaneous defect. Method: This 10-year study includes 73 patients who underwent modified pectoralis major flap reconstruction for complex laryngo-pharyngeal defects following resection of tumours involving larynx, hypopharynx oropharynx and cervical oesophagus. The modified technique involves accommodating a deltopectoral fasciocutaneous flap which rotates over the pedicle to insert into the neck incision providing extra tissue to achieve a tension free closure. Results: 73 patients underwent the procedure, 80% were male. Mean age of patients was 62.8years. Larynx was the most common site and the average size of the tumour was 34.8 mm. 13 patients developed minor complications such as wound dehiscence out of which 10 were managed conservatively, 3 patients required additional reconstructive procedures. 13 patients developed pharyngocutaneous fistula and 6 developed Neopharyngeal stenosis. 51 patients achieved good swallowing and 55 developed intelligible speech following recovery. Conclusion: We recommend the use of this technique as an effective method to achieve tension free neck incision closure and improved cosmetic results especially in centres which do not have free flap facility readily available.

Surgical Treatment of Stage Four Knee Pressure Injury with Pedicled Fasciocutaneous Flap in Patient Affected by Spina Bifida - Case Report.

Introduction: Patients affected by spina bifida (SB) can present varying degrees of paralysis, limited mobility, impaired sensation, orthopedic problems and bowel, bladder, and renal impairments. Skin wounds are reported as one of the primary diagnosis associated with hospitalizations in SB affected patients. In young patients, pressure injuries can occur more frequently at the lower limb. A multidisciplinary approach and a proper surgical technique are mandatory to obtain favorable long-term outcomes, in terms of adequate coverage and risk of recurrence. Case Presentation: A Caucasian male 21-year-old wheelchair-bound patient with history of SB was admitted to our department with stage four pressure injury on the medial aspect of knee joint and osteomyelitis. After antibiotic therapy wound preparation and debridement, we covered the pressure sore with a pedicled fasciocutaneous flap harvested from the medial compartment of the thigh. In the distal part, we splitted the fascia from the flap and used it to reconstruct the exposed knee joint. We did not report any complications and no recurrence was observed at 1-year follow-up examination. Conclusion: In this reported case, the multidisciplinary approach and the surgical technique allowed us to cover the soft-tissue defect around knee joint, reducing morbidity, surgical time, and cost with good long-term outcomes.

Simultaneous reconstruction of septic composite defects in lower extremities: Combination of fasciocutaneous perforator flap and Masquelet technique.

Background: Management of composite defects with deep infection is a challenge to reconstructive surgeons. This study aimed to demonstrate the versatility, safety, and complications of simultaneous reconstruction of infectious composite defects with fasciocutaneous perforator flap combined with the Masquelet technique. Methods: This study presents 10 patients in whom a fasciocutaneous perforator flap combined with the Masquelet technique was used to restore soft tissue and bone defects of the lower extremity, and were admitted in two level 1 trauma centers in Shanghai. The first stage included debridement of necrotic bone and infected tissues, implantation of a polymethylmethacrylate cement spacer to cover the void; bridging fixation of the osseous defect using external or internal fixators, and soft-tissue reconstruction with a fasciocutaneous perforator flap. The second stage included cement spacer removal with membrane preservation, refreshing bone edges, and grafting the cavity with bone morphogenetic proteins and autologous iliac bone graft. Results: The mean follow-up duration after autologous bone graft was 17.5 months. The average bony defects and average flap dimensions were 7.1 cm and 44.9 cm2, respectively. All flaps survived uneventfully. No recurrence of infection was detected in either the second stage of surgery or follow-up period. The mean duration of bone consolidation was 31.9 weeks. One patient had a 2 cm leg length discrepancy, and one patient had mild foot drop. No residual deformity requiring a secondary procedure occurred. Conclusion: Fasciocutaneous perforator flap combined with Masquelet technique provides a reliable and versatile alternative for patients with composite defects resulting from lower extremity infection.

Common Flaps in Genitourinary Reconstruction.

Urethroplasty has evolved over time. The twentieth century saw management of urethral strictures and hypospadias with flaps. Things changed in the late 1990s with reintroduction of grafts. Buccal mucosa grafts gained popularity. There are failed urethroplasties and obliterative strictures, mostly iatrogenic, after urologic endosurgery. Such strictures need vascularized augmentation or substitution with flaps. Reconstructive urologists should be well versed in management of all types of complex cases. This article discusses the commonly used flaps in genitourinary reconstruction. Penile flaps are the commonest. Overall, the winner is the dartos. All penile flaps are based on the excellent vascularity of dartos.

Use of Biologic Agents in Extremity Reconstruction.

Skin and soft tissue defects of the lower extremity present a unique challenge for the reconstructive surgeon. Successful repair of the lower extremity relies not only on strong anatomical knowledge and surgical expertise, but also on careful consideration of the numerous preoperative factors and indications that may alter the patient's response to operative management. While many of these injuries result from burns, avulsive trauma, diabetes, or vascular insufficiencies, a significant portion can be associated with resection of neoplastic pathologies. This review outlines the uses, indications, and considerations for biologic wound agents in reconstructing skin and soft tissue defects of the lower extremity following Mohs micrographic surgery.

Management of a Bronchopleural Fistula After Right-Sided Lobectomy Using a Delayed Random Flap Under Guidance of Indocyanine Green (ICG) Angiography: A Case Report.

Bronchopleural fistula (BPF) following lung resection and thoracic surgery is associated with high rates of morbidity and mortality. Various methods are available for the closure of BPF and thoracic dead space, including flap procedures and thoracoplasty. While delayed random flaps have been used for the treatment of BPF and closure of thoracic dead space, no previous reports have described the concurrent use of laser-assisted indocyanine green angiography (ICG-A). We report a case of successful BPF closure with a random delayed fasciocutaneous flap using laser-assisted ICG-A guidance for flap delay.

Medial thigh fasciocutaneous flaps for reconstruction of the scrotum following Fournier gangrene: A case report.

Fournier's gangrene, a rapidly progressive necrotizing fasciitis of the perineum and external genitalia that leads to extensive soft tissue necrosis, remains a medical-surgical emergency. The authors present a case of coverage of a scrotal loss of substance with testicular exposure by a medial fasciocutaneous flap of the unilateral thigh after debridement and initial medical treatment of Fournier's gangrene in a 50-year-old quadriplegic patient. The clinical examination at 8 months showed an aesthetic and functional result. The trophic-cutaneous thigh flap that the authors propose for frail, elderly, and neurological subjects with low functional requirements allows coverage of the scrotal region with relatively thick skin, color, and texture close to those of the scrotum. It also offers technical simplicity, moderate scarring, and functional remnants at the price of less morbidity.